Cognitive Behavioural Therapy (CBT)

Cognitive Behavioural Therapy (CBT) has become a popular treatment of choice for many health authorities around the world for a host of psychological problems, from clinical depression to bulimia nervosa and obsessive compulsive disorder. But what exactly is CBT?

Therapies are not all equal

It used to be thought that in order to help someone change unwanted patterns of emotional difficulty it was important or essential to ‘find the root cause’ of their difficulty.

The assumption was that once the initial trigger was ‘discovered’, this insight would free the sufferer from their problem. Uncovering this ‘root’ is an important aspect of ‘psychodynamic therapy’, but has not been shown to be particularly helpful in alleviating conditions such as depression, anxiety or addiction (1) – and it may even make some conditions get worse.

The ‘toxic effect’ of some therapeutic approaches may be because they often mirror what a depressed person is already doing – like endlessly dwelling on bad stuff from the past without focussing on solution orientated behaviours to help their futures. (2)

CBT was developed from theories drawn from both cognitive and behavioural psychology and is based on the theory that thoughts precede and produce feelings. So by changing a person’s thinking and beliefs you can change their feelings.

Cognitive psychotherapy joins forces with behavioural psychology

‘Behaviourism’ focused on the idea that changing behaviour alone would change feelings, while cognitive theory focused on the importance of changing thinking. (3) Both approaches seemed reasonable and the two together seemed a match made in heaven. The significant breakthrough of CBT was that at least (at last!) it was solution focussed and constructive, and not just fixated on the problem. The idea was to help people change through teaching them to think and act differently, not just help develop some theory as to what had ’caused’ their emotional difficulties.

But CBT might not be quite as effective as was initially hoped – and here’s why:

Potential problems with Cognitive Behavioural Therapy

One problem with CBT is that its basic premise, that thoughts happen before feelings, is fundamentally wrong. Of course, thoughts and feelings are intertwined, and influence each other, but emotion has to happen quicker than thought, because it’s (potentially) vital for survival. (4)

Albert Ellis, the originator of ‘rational emotive behavioural therapy’ (an early form of CBT), devised the ‘ABC model’ to explain the interplay of thoughts and feelings:

A Activating agent – the thing that gets you upset or makes you want to smoke a cigarette or wince at the sound of an explosion.

B Beliefs or thoughts you have about what has happened.

C Consequences of those thoughts or beliefs – such as you feeling frightened or tipping into an addictive binge.

This doesn’t stand up to scrutiny – and is not even common sense.

For example, if you were to suddenly hear a loud explosion next door, you wouldn’t first think: “I wonder if that was a bomb going off?” and then feel a rush of adrenaline because of what you had just thought.

What would actually happen is that your fight-or-flight response would kick in before (around half a second before) you had any thoughts about it at all. The feeling of fright would then produce the thought: “What was that!” which might then be followed by the belief: “We’re being attacked!” Half a second may not sound like a lot to you, but in terms of synaptic activity in your brain, and activation of your fight-or-flight response, it’s ages.

Psychotherapy needs to be based on common sense and science

People will often justify why they behaved as they did after the event. Trying to get a PTSD sufferer to stop having flashbacks or panic attacks, or a phobic to stop reacting automatically to their trigger, or an addict to stop reaching for their fix, by getting them to change their thinking or beliefs is tantamount to trying to prevent an explosive device from going off by wandering around in the rubble after the explosion.

We believe it is essential to reach the feeling part of human response to psychological problems and work on that, and some kind of hypnotic intervention is the most effective way to do this. When the feeling changes, the thinking will often fall into line with the new healthier way of feeling.

A new model for human response

Psychotherapists Ivan Tyrrell (5) and Joe Griffin outlined a more useful and scientifically validated model in their seminal work Human Givens: A new approach to emotional health and clear thinking(6) with their APET model:

A Activating agent – the thing that gets you upset or makes you want to smoke a cigarette or wince at the sound of an explosion (just as with the ABC model)

E Emotional response produced by the preceding pattern match (e.g. a war veteran feeling panic on hearing a car backfiring)

T Thoughts about what happened (such as, “Oh, it was a car backfiring”)

This model is in complete accord with what neuroscientists have established about how the brain actually works and totally undermines the fundamental theoretical basis of CBT. Oh dear!

But there are other problems with Cognitive Behavioural Therapy.

Keep it simple stupid!

A common problem with many different psychotherapeutic approaches is over complication. We often wonder about this – is all that jargon generated in order to convince people that this approach is respectable or sophisticated? Why do clients have to learn lots of theoretical jargon and fill in complicated forms if they want to feel better?

A good therapist should build rapport with their client by learning and using the kind of language the client uses. A computer scientist client who had previously had CBT reported to us that even he had found all the sheets to fill in and all the analysis of his own thinking way too complicated!

Of course, CBT really does help some people. Focussing on thoughts instead of feelings may work as a distraction, and thus reduce negative feelings. And focussing on solutions and positive outcomes is, in itself, genuinely therapeutic. But the fact remains that it’s much easier – and quicker – to change feelings and emotional responses and then focus on underlying thoughts and assumptions (which so often arise from the feelings rather than vice versa).

But CBT has been shown to be effective hasn’t it? Well…

Just how effective is Cognitive Behavioural Therapy?

Although CBT is a popular treatment of choice at the moment and has had a good press and does have a lot to contribute, it is seriously hampered by its unsound theoretical basis and over complexity.

A year long study published in 2001 found that CBT was no more effective than a course of non-directive therapy or even a few short visits to the doctor (GP) in the treatment of depression. (7)

And according to this article and the research it cites researchers have found that CBT is roughly half as effective for the treatment of depression as it used to be. The orginal paper is here.

So why might CBT be becoming less effective? This may be due, as the article suggests, to public expectation and the placebo effect. Expectation tends to be negative with depressed people but anything that can engender positive expectation or hope, will help lift the depression. This is one reason depression is so amenable to placebo, more so than say, cystic fibrosis. When CBT was new it was widely touted as the latest wonderkid on the block. But it may have fallen victim to its own success.

Another reason for the downturn in efficacy may be because as CBT developed it seemed to change from quite a simple and useful insight – that thoughts are related to feelings and behaviours – to increasingly complex theories, techniques and jargon.

If CBT is to regain its former efficacy it will need to incorporate the skills of creating positive expectation in clients as part of the skill set.

A way forward

When choosing what kind of psychotherapy to undertake, we think it’s important to find a practitioner who

understands the role of emotions in the mind and how they actually work

can build rapport with the client by talking their language rather than psycho-jargon and

can work hypnotically so that feeling responses can be quickly changed if necessary.

Therapy should be brief, helping a person as quickly (and cheaply) as possible and solution focussed.

A meta-analysis of hundreds of studies found that this type of approach was better than any other in the treatment (including drug treatment) of depression, anxiety disorders, phobias, traumas and addictions. (8)